Humiston, Elizabeth Ntw YORK STATE DEPARTMENT OF HEALTH i • 1 # Ill
I Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Elizabeth Lorena Humiston Female
. . Date of Death Age If Veteran of U.S. Armed Forces,
March 5, 2013 90 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Argyle Street Address Pleasant Valley
Manner of Death 0 Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Edit Masaba, MD Dr.
Address
97 200 Main Street Greenwich, NY 12834
Death Certificate Filed District Number Register Numb
City, Town or Village Argyle 5'J
❑Burial Date Cemetery or Crematory
March 6, 2013 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
x;; Date Place Removed
Removal and/or Held
and/or Address
Hold
1 ' Date Point of
-_❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
-99
PI EI Reinterment
ot
Date Cemetery Address
fig" Permit Issued to Registration Number
97 Name of Funeral Home M. B. Kilmer Funeral Home 01077
Address
123 Main St., Argyle NY 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
- Permission is hereby granted to dispose of the human re 'ns describe above as indicated.
Registrar of Vital Statistics �In( (/U14 - --
Date ISSued,�� CD3 (signature)
District Numberr)a) Place if i l/�
t
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
r
Date of Disposition 03/06/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) A , or number) (grave number)
t.°v Name of Sexton or Person in Charge of P emises �'�} '" �""��
(iiease pant)
Signature Title
ce '@�
9
(over)
DOH-1555 (02/2004)